SARS From Behind The Mask

never knew how much I relied upon lip-reading in my job as an emergency physician,
until I became unable to see the faces of my patients. For the past two weeks,
going to work in a SARS-protected environment has meant spending hours smothered
in an N95 mask, wrapped in an isolation gown, wearing eye protection, and gloves.
Patients in the emergency department are masked as well, so we peer at each other
like disembodied eyes and hairstyles. Suddenly, I cannot understand what anyone
is saying. Words are usually obscured by accents and the noise of the emergency
department, but now they are also muffled by the mask material itself and I cannot
watch people's lips. I now realise how much I need to see the movement of
lips to understand speech.

"I see berry berry vizzy," says my patient.

"What?" I say.

"I see fizzy," says my patient.

"You feel dizzy?" I say.

My patient nods, finally.

Already, SARS is becoming a 'new normal' for those of us who continue
to work in Toronto hospitals. Many hospital clinics are closed, but for those
of us who remain in what are deemed to be essential services, we are becoming
accustomed to lining up in a tent in the back of the hospital in order to get
into work. All the entrances are sealed except the emergency entrance, where patients
pass through a parked TTC bus to be screened, and the back entrance where staff
are processed in the tent. There, our temperatures are taken as we file past infection
control workers with thermometers. We answer daily questionnaires about our physical
condition, whether we have worked at other hospitals, whether we have travelled,
and whether we have cared for SARS patients. If we are deemed to be 'clean',
we are issued our daily gown and mask, which we must don in order to enter the
hospital, and can go in to work. Each day there seem to be different models of
masks, and staff members are developing individual preferences regarding masks.
All of them are smothering and hot. One of the nurses in the emergency department
brought smiley stickers, which could be scratched and sniffed to release a strawberry
scent. On that day, we had strawberry smiley stickers on the exhalation ports
of the N95 masks.

One of my fellow physicians refused to have a sticker on his mask, saying,

"There's nothing funny about this."

He's right, of course. It's not funny, and we're all scared.

During normal times, the emergency department carries a sense of rough and ready
fatalism. Bad things happen, and disaster wheels in - sirens blaring. We jump
into the fray, try to save a life, and then the next patient rolls in. Now, we
feel that the danger of SARS lurks in our midst, and more than just responding
to it, we may become its victims. Many of the SARS cases in Toronto have been
amongst health-care workers. Even though SARS patients are isolated from the public,
we must continue to care for them. For us, it is not far away. We are comforted
by the fact that SARS has reached health care workers only, seemingly, before
current infection control measures were undertaken.

It is the unknown which is most sinister. At present, laboratories around the
world spend sleepless night trying to isolate the SARS pathogen. The mode of transmission
is unclear but our main line of defence, quarantine and isolation, is an effort
to break transmission. So, we are fighting an enemy that we cannot see with weapons
of unknown effect. What we grasp are the screening questionnaires and treatment
protocols which outline who should be suspected of SARS, who should be isolated,
who should have the myriad swabs and tests drawn, who should be admitted to hospital,
and who should simply be reassured that, as far as we can tell, they do not have
SARS.

The protocols have been changing. Before leaving for each shift at the hospital,
I check my Email to know if the guidelines are different today. I print out the
flow-charts, to see if all the little arrows go to the same boxes they led to
on the last flow-chart. Patients that we would have sent home in the first days
of the outbreak are now being admitted to hospital. It is normal for things to
change in medicine, for dogma to be contradicted by a new finding, and for a new
way of treatment to render another incorrect. However, this usually happens over
years, and we have time to nurse our old folly and coddle our new wisdom. Now,
with our knowledge of SARS changing daily, we have no time to lull ourselves into
any illusion of understanding. The staff in the emergency department all follow
the daily number of cases, the number of fatalities. It is like watching flood
water rise at a dike, and wondering if it will overflow.

I and a fellow physician were deciding how to manage a patient who was struggling
to breathe. We decided to isolate the patient and treat him as a suspected SARS
case even though he did not meet the criteria in the flow-chart of that day. Why
did we do this? The situation of this patient who was struggling to breathe didn't
quite make sense. It just 'didn't look right' to our 'clinical
instinct', that sacred gut reaction of medicine. My colleague said,

"If we don't isolate him now, we may look back and think we were idiots."

What he meant is that if we missed one case because it didn't fit the guidelines,
the potential consequences could be immense. Days after, the protocol was altered
to accommodate the consideration of SARS in patients such as this who presented
with apparently other respiratory problems in an 'atypical manner'.
As a profession, we're still figuring it out.

In the lounge, there is mostly quiet, and the little talk is about SARS. At breaks,
everyone drinks water. The masks cause a very dry mouth  it's like
working in a hot fog. One of the nurses said one night,

"If I thought that coming to work I could catch something that could kill
me, I wouldn't come to work."

This thought has crossed many of our minds, of course. We hope that none of us
will contract SARS or die from it, and I know of no one who has stopped coming
to work out of fear. I keep on thinking that this is what health care has always
been like, that in the past few decades we in North America have been briefly
sheltered from humanity's long history of plagues, epidemics, and deadly
scourges. It makes me think that maybe we've had a bit of a honeymoon, that
perhaps now we're getting a little taste of the real marriage between humanity
and infectious disease.

Early in the outbreak, I advised a woman that she would need to be admitted to
hospital for emergency surgery to treat a life-threatening problem. She agreed
but asked me anxiously,

"Tell me the truth, do you have SARS in this hospital?"

At that time, my answer was that we did not. The patient was very relieved, despite
her other medical problems. Now, my answer would be different. We now have SARS
patients who have come through our emergency department and are admitted to our
hospital. For the moment, our clinics remain closed, and in the emergency department
we try to be vigilant for SARS, care for all of our patients through our mask
and gown barriers, and protect ourselves.

The masks, in addition to making it difficult to understand speech, impair much
other communication. My conversations with patients seem distant and impoverished
when I cannot see a grimace, or the understanding of a grin. These expressions
contain many unspoken clues to diagnosis, as well as a sense of a person's
human situation. My patients seem in danger of becoming random garbled speech
emanating from a blue mask perched on top of a body. I must seem equally surreal,
as a doctor floating through the room in my gown, waving my white-gloved hands.
I find myself gesturing more, using a sort of mime to transmit the meanings that
usually find themselves in my face.

For the moment, we in the hospitals continue to watch the flood of new cases,
of daily news reports, and of the strange changes in our workplace filling our
dike. We hope that this flood will not overflow into the community around us.
It is a pleasurable freedom to leave work, to be able to breathe, to sit in a
restaurant and understand what people are talking about. The number of new SARS
cases seems to be slowing. It's too early to say what will happen, but hopefully
it will burn itself out and leave us with a new appreciation of being able to
see each other's faces. If not, we will continue to learn about SARS and
about ourselves.